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1166 E. 28TH AVENUE, EUGENE, OR 97403
110 beds · For profit - Limited Liability company Wheelchair accessible
CMS Provider #385167
Data updated: March 1, 2026
Overall Rating
★★★★★
Health Rating
★★★★★
Staffing Rating
★★★★★
Quality Rating
★★★★★
Daily nursing care
5.5 hrs/resident
Steady
Inspection findings
13
More issues
Ownership changes
0
Owned by Volare Health, a for-profit chain of 16 facilities.
Complaint trend
More complaints
26 complaints resulting in inspection findings within the last two cycles.
Overall Rating
Health Inspection
Staffing Rating
Quality Rating
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South Hills Rehabilitation Center is a Special Focus Facility with high nursing turnover and a recent history of federal fines and abuse-related citations.
The data for South Hills Rehabilitation Center indicates significant variations from state averages across health and staffing metrics. While the facility provides 5.51 total hours of nursing care per resident per day—exceeding the Oregon state average of 4.95 hours—the composition of this staff reflects high instability. Records show a registered nurse turnover rate of 90% and a total nursing staff turnover of 73%, compared to state averages of 53% and 49%, respectively. Furthermore, 43% of registered nurse hours are provided by contract or agency staff, which is nearly triple the threshold generally associated with consistent continuity of care.
The facility’s health inspection history includes 13 findings in the most recent cycle and 43 in the previous cycle, significantly higher than the state average of 10.4 findings per cycle. Specific citations include failures to protect residents from abuse and neglect, as well as issues with respiratory care and medication self-administration. Financial records show a recent federal fine of $121,905 issued in August 2025. While the facility maintains a quality measure rating of 3 out of 5 stars, its status as a Special Focus Facility and the presence of a consumer alert for abuse are the primary drivers of its current data profile.
Federal records indicate the facility is currently designated as a Special Focus Facility, a status reserved for homes with a history of persistent safety and care quality issues.
The facility has an active abuse icon on its public profile, indicating citations related to the protection of residents from abuse or neglect.
Registered nurse turnover is 90%, approximately 37 points higher than the Oregon state average of 53%.
This shows how the facility's federal ratings have changed over the past 24 months. Consistent high ratings suggest stable quality, while declining trends may warrant further investigation.
| Category | Apr 24 | Jun 24 | Aug 24 | Oct 24 | Dec 24 | Mar 25 | May 25 | Jul 25 | Nov 25 | Jan 26 | Mar 26 | Trend |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall | 2★ | 1★ | 1★ | 1★ | 1★ | 1★ | 1★ | 1★ | 1★ | 1★ | 1★ | |
| Staffing | 1★ | 1★ | 1★ | 2★ | 2★ | 2★ | 3★ | 3★ | 1★ | 1★ | 3★ | |
| Health | 3★ | 2★ | 1★ | 1★ | 1★ | 1★ | 1★ | 1★ | 1★ | 2★ | 1★ |
Staffing depth is the strongest predictor of care quality. Facilities routinely cut staff on evenings and weekends — the shifts when falls happen and call lights go unanswered.
RN Hours Specifically
State avg total staffing: 5.0 hrs/resident/day
1
administrator departed in past year
Some change73.0%
State avg: 49.1%
90.0%
State avg: 53.0%
22.0%
of nursing hours from contract/agency staff
ElevatedSource: PBJ data, 2025Q3
A facility's location matters — nearby hospitals, pharmacies, and public transit can make visits easier and ensure quick access to emergency care.
Walk Score
70
Very Walkable
Transit Score
36
Some Transit
Median Income
$47,021
Median Home Value
$496,700
Poverty Rate
34.0%
Age 65+
10.5%
Median Age
22
Pop. Density
15,303/mi²
Median Rent
$1,128
Google reviews provide firsthand accounts from residents' families and visitors.
★★★★★
61 reviews
"They weren't watching my mom properly.. she fell and hit her head..making her wait for 2 hours before contacting us!!? DO NOT LEAVE YOUR FAMILY HERE!!! They manipulated me into leaving my mom there because of some famous ice skater they have there. Most of their staff is amazing, but their noc shift nurses suck!! We had to bring her food and her own bedding."
"My dad came here and over the span of my time visiting, the whole place reeked of urine, floors were sticky. The paper towel dispenser in my dad's bathroom didn't work and they never fixed it despite telling them several times. The remote control for the television in his room didn't work, I ended up fixing it myself. I asked them to have the person responsible for taking care of my dad to contact me with details of his treatment plan, they never did. When my dad was discharged they lost his clothes and sent him home by himself in a diaper and his gown, despite his mobility issues. Everyone seemed friendly, but they need to be more attentive."
"I have very little good to say about how my spouse was treated at this facility. I spent 8-9 hours with him per day and he commonly spent the entire day with very few staff members ever stopping in, and that was usually just for medication given to him, or meals. I asked the Nurse what the medications were and she stated she couldn't pronounce the names. They seemed to avoid helping with toileting, it seems possibly because I was there and they assumed I could help him. The Nurse Practitioner who saw him was excellent, and caring. The rehab (PT, OT, speech) initial evaluation was thorough, but daily rehab just didn't happen, to actually attempt to strengthen him, after the initial evaluation, not sure why. I would ask to have the nurses and other staff to make sure rehab providers knew we wanted them to come by when they were in the center, and often later found out the rehab providers had come and gone without seeing him."
"My 88 year old Mother was sent to South Hills Rehab, after falling and breaking a hip, see spent quite a while on the rehab floor, where it was decided, that her returning to her previous residence would not be possible. She was then moved upstairs to the residential floor, where she stayed for several months, the staff on both floors were always very attentive to her needs, they were friendly and understanding of the stresses involved in an elderly individual going through so many changes at once. We visited on numerous occasions and the staff was always friendly and courteous, to us and our mom, the only reason we moved her out of there was due to the fact it was over 100 miles one way for any of us to visit, so she was moved to a facility closer to our homes. I want to thank all the staff on both floors for being such an awesome care team. You guys/girls are the best. I would recommend South Hills rehab highly, to anyone."
"I don’t understand the negative reviews because my experience was the complete opposite The staff are very attentive and caring. The food is exceptional for an institutional setting. The building is clean and there is a space to go outside and enjoy the sun and trees. My walking improved after spinal surgery with the help of the excellent therapy I received. I would highly recommend South Hills Rehab to anyone looking for a skilled nursing facility."
"I have been at the facility everyday for the past three months hoping my mother will get well enough to go home soon. My experience has been amazing-everyday!! The LPN’s, CNA’s PT’s, OT’s, house keeping and regular staff have been nothing but caring and professional. Folks this is a very difficult profession, but everyone I’ve crossed paths with has shown they care deeply about their roles snd every residents wellbeing. Each staff member takes the time to explain the why’s and the why not’s whenever I’ve had questions or concerns. I wish I could name you all-but it would not be fair because I’m not able to be there 24/7. I can say however, another family member also spends a lot of time in the facility and feels exactly the way I do. Please know, we appreciate each and everyone for their hard work and dedication each and every day. Nothing but respect!!"
"I am currently a patient here. The CNAs are wonderful and very helpful. I had a Huge back surgery and the therapist have been wonderful as well. I have been here for 7 days I think now and I had a dr appointment that took 5 hours because the facility had the wrong time. 5 hours in a wheel chair is a very long time when I came back my lunch2 was very cold and I didn't like the meatloaf when I asked for something else well the kitchen was closed. So when it was dinner time again I didn't like what was served so I asked 4 different cnas for a chef salad and they left and never came back. So therefore I missed lunch and dinner yesterday. I did get a sandwich from nurses fridge but I still thought I deserved to have a meal. Not really sure what happened there but over all I have received great care I at times have trouble with my pain meds. I will ask for them and it will take an hour or more to finally recieve them. But I wanna thank you for all my care. I know it can be alot and I thank you with all my heart for my care."
"They didn't shower my mother in over 10 days. She's a vegetarian yet they brought her a plate full of meat and then says they were going to get " aggressive " if she didn't eat enough then stopped bringing her food all together. They brought in another patient's medications and luckily we had a family member there that caught that that wasn't the correct name before she ingested them. They brought in a bedside commode covered in fecal matter from another patient's room. Not to mention how they roughed her up to get out of bed because she just had hip surgery and can't walk yet but they were impatient. Also they don't care that she can't hear without hearing devices but didn't turn the hearing device on to communicate with her so she had no idea what they were saying but they were getting mad. There's so many more reasons that I would never leave my loved one in this facility if you want them to survive."
"I'm currently having a terrible experience with this place. My grandmother complained that the meat was too tough to chew so they are now blending ALL OF HER MEALS. We have asked them to stop several times and they refuse. Our family members are now bringing food to my grandmother in this facility. They are also not changing her regularly (incontinence) or getting her out of bed even once a day for physical therapy. If I had the power to pull her from their care I would immediately. She was in the hospital for a week before ending up here and in the hospital she was EATING SOLID FOOD AND WALKING."
"South Hills is an amazing facility. Located in the beautiful South Hills of Eugene, Oregon. From the moment you walk through the door, you are greeted by kindness and smiling faces. The staff are all friendly from the beginning, the food options are great, and the facility is kept nicely clean by the wonderful housekeeping staff."
Federal and state inspectors conduct regular surveys of every nursing home. Deficiencies listed here are problems found during those inspections.
| Date | Tag | Category | Description | Severity | Corrected | Type | IC |
|---|---|---|---|---|---|---|---|
| 12/9/2025 | 0695 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | Minimal harm | 1/5/2026 | Complaint | |
| 12/9/2025 | 0684 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Minimal harm | 1/5/2026 | Complaint | |
| 8/11/2025 | 0814 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | Minimal harm | 9/29/2025 | Standard | |
| 8/11/2025 | 0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Minimal harm | 9/29/2025 | Standard | |
| 8/11/2025 | 0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Minimal harm | 9/29/2025 | Standard | |
| 8/11/2025 | 0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | Minimal harm | 9/29/2025 | Standard | |
| 8/11/2025 | 0628 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Minimal harm | 9/29/2025 | Standard | |
| 8/11/2025 | 0684 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Minimal harm | 9/29/2025 | Standard | |
| 8/11/2025 | 0689 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Minimal harm | 9/29/2025 | Standard | |
| 8/11/2025 | 0812 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Actual harm | 9/29/2025 | Standard |
When inspection deficiencies are serious enough, the government may impose financial penalties or deny Medicare/Medicaid payments.
Total Penalties
1
Total Fines
$121,905
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 8/11/2025 | Fine | $121,905 | — |
Ownership structure and changes can affect facility quality.
Facilities in Chain
16
Chain Avg Rating
1.7 ★
Years Operating
40
| Owner Name | Type | Role | Ownership % | Association Date |
|---|---|---|---|---|
| PAC 12 OPCO HOLDCO LLC | Organization | — | 100% | 3/1/2023 |
| KNOX HEALTHCARE PAC 12 HOLDINGS LLC | Organization | — | — | 3/1/2023 |
| PAC 12 HOLDINGS LLC | Organization | — | — | 3/1/2023 |
| PAC 12 PINNACLE HOLDCO LLC | Organization | — | — | 3/1/2023 |
| HAGAR, CHAIM | Individual | — | — | 3/1/2023 |
| HAGLER, ALEXANDER | Individual | — | — | 3/1/2023 |
| KNOX, DONALD | Individual | — | — | 3/1/2023 |
| SCHWARTZ, ELIEZER | Individual | — | — | 3/1/2023 |
| VOLARE HEALTH LLC | Organization | — | — | 3/1/2023 |
| DUNHAM, SARAH | Individual | — | — | 4/1/2025 |
| KNOX, DONALD | Individual | — | — | 3/1/2023 |
| MURER, EMILY | Individual | — | — | 3/10/2025 |
| SCHWARTZ, ELIEZER | Individual | — | — | 3/1/2023 |
| KNOX, DONALD | Individual | — | — | 3/1/2023 |
| SMITH, BRIAN | Individual | — | — | 3/27/2023 |
| CAMAS RIDGE PROPCO LLC | Organization | — | — | 3/1/2023 |
| PAC 12 OPCO HOLDCO LLC | Organization | — | 100% | 3/1/2023 |
| KNOX HEALTHCARE PAC 12 HOLDINGS LLC | Organization | — | — | 3/1/2023 |
| PAC 12 HOLDINGS LLC | Organization | — | — | 3/1/2023 |
| PAC 12 PINNACLE HOLDCO LLC | Organization | — | — | 3/1/2023 |
| HAGAR, CHAIM | Individual | — | — | 3/1/2023 |
| HAGLER, ALEXANDER | Individual | — | — | 3/1/2023 |
| KNOX, DONALD | Individual | — | — | 3/1/2023 |
| SCHWARTZ, ELIEZER | Individual | — | — | 3/1/2023 |
| VOLARE HEALTH LLC | Organization | — | — | 3/1/2023 |
| DUNHAM, SARAH | Individual | — | — | 4/1/2025 |
| KNOX, DONALD | Individual | — | — | 3/1/2023 |
| MURER, EMILY | Individual | — | — | 3/10/2025 |
| SCHWARTZ, ELIEZER | Individual | — | — | 3/1/2023 |
| KNOX, DONALD | Individual | — | — | 3/1/2023 |
| SMITH, BRIAN | Individual | — | — | 3/27/2023 |
| CAMAS RIDGE PROPCO LLC | Organization | — | — | 3/1/2023 |
Recent news articles, lawsuits, and media coverage mentioning this facility.
No recent news coverage found for this facility.
Data updated: March 1, 2026 · CMS, OSCAR, state inspection records
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